ATI RN
ATI Fundamentals 2023 Retake Questions
Extract:
Question 1 of 5
A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Hold bottles of sterile solution with the label in the palm of the hand. This is important to maintain sterility as it prevents contamination from the label touching non-sterile surfaces. Holding the bottle in the palm of the hand also helps prevent accidental spills.
Choice A is incorrect because opening the outermost flap of the sterile kit toward the body can cause contamination.
Choice C is incorrect as pouring liquids into containers outside the sterile field can introduce contaminants.
Choice D is incorrect because placing the sterile field at the level of the nurse's hips can increase the risk of contamination from the nurse's clothing.
Question 2 of 5
How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis?
Correct Answer: D
Rationale: The correct answer is D: Strike a flat hand covering the costovertebral angle (CV
A). This method is known as CVA tenderness test and is used to assess for flank tenderness specifically related to kidney inflammation like pyelonephritis. By striking the CVA, the nurse can elicit pain or tenderness in the affected kidney area. Percussing between the iliac crest and ribs (
A) is used to assess for liver size. Pushing fingers upward into the intercostal spaces (
B) is done to assess for splenomegaly. Palpating along the lumbar vertebral column (
C) is not specific for flank tenderness related to pyelonephritis.
Question 3 of 5
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, 'I want to die now that my partner is gone.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale: Answer B is correct because it directly addresses the client's statement about wanting to die, which indicates suicidal ideation. By asking if the client has thought about harming themselves, the nurse is assessing the client's risk of self-harm and can then take appropriate actions to ensure the client's safety.
Answer A is incorrect as it focuses on the medication issue rather than the client's immediate safety. Answer C is incorrect as it shifts the focus away from the client's suicidal thoughts. Answer D is also incorrect as it doesn't address the immediate risk of self-harm and instead suggests discussing the feelings with the provider without assessing the client's safety first.
Question 4 of 5
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?
Correct Answer: D
Rationale: The correct answer is D: Secure the tracheostomy in place with a collar that has hook-and-loop fasteners. This is important to prevent accidental dislodgement of the tracheostomy tube. The collar provides stability and security, reducing the risk of complications such as airway obstruction. It also allows for easy adjustment and removal if needed.
A: Wearing clean gloves is important, but it is not directly related to tracheostomy care.
B: Hydrogen peroxide is not recommended for cleansing the skin around the stoma as it can be irritating and drying to the skin.
C: Placing a gauze pad under the flanges is not necessary and may increase the risk of infection or skin breakdown.
Overall, option D is the most appropriate action for tracheostomy care.
Question 5 of 5
A nurse is caring for a client who has severe rheumatoid arthritis in her hands and is unable to feed herself. For which of the following health care team members should the nurse request a referral from the provider?
Correct Answer: C
Rationale: The correct answer is C: Occupational therapist. An occupational therapist specializes in helping individuals with physical limitations perform activities of daily living, such as feeding oneself. They can provide adaptive equipment and teach techniques to promote independence. Referring the client to an occupational therapist will address the specific needs related to the client's severe rheumatoid arthritis in her hands.
A: Physician assistant focuses on medical diagnosis and treatment, not specifically on activities of daily living.
B: Physical therapist focuses more on mobility and physical rehabilitation, not specifically on activities like feeding.
D: Social worker focuses on psychosocial aspects and support services, not specifically on physical rehabilitation.
Therefore, the best choice for addressing the client's feeding difficulty due to severe rheumatoid arthritis in her hands is to request a referral to an occupational therapist.